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WALNUT GROVE PLAZA PHARMACY #2
DSH440130 BAPTIST MEM HOSPITAL UNION CITY
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Covered Entity Details
Entity Name
BAPTIST MEM HOSPITAL UNION CITY
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH440130
Entity Address
1201 BISHOP STREET
UNION CITY, TN 38261
Medicare Provider Number
440130
Participating Start Date
4/15/2020
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
WALNUT GROVE PLAZA PHARMACY #2
Pharmacy Address
6027 WALNUT GROVE RD
STE 110
MEMPHIS, TN 38120-2115
Pharmacy Comments
Contract Details
Approval Date
7/18/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
David Barham, VP, Operations Finance CFO
(901) 227-7467
Contract Pharmacy Representative
Baptist Memorial Health Care Corp
Donna C Cox, Director 340B
(901) 227-5144
Signed By Date
7/18/2017
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